F0744

D

Resident Placed on Secured Memory Care Unit Without Dementia Diagnosis or Documented Need

Scottsburg, Indiana Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident placed on the secured memory care unit had an appropriate dementia-related diagnosis or documented clinical need for that placement. The resident, who had diagnoses including diabetes, end-stage renal disease, major depressive disorder, anxiety, and bipolar disorder, was ordered by a physician on 7/18/25 to reside on the secured unit. The resident’s care plan dated 8/30/25 documented that the resident lived on the secured unit related to dementia and exit seeking, with interventions such as activities per schedule, secured unit per physician order, and review and assessment of appropriate placement. However, the clinical record lacked any diagnosis of dementia, Alzheimer’s disease, or other irreversible dementia, and there was no documentation supporting a clinical need for a secured unit. The resident’s former primary care physician stated that the resident did not have a dementia diagnosis and that he would not have initiated an order for placement on the dementia unit. The facility’s Memory Springs admission/discharge criteria required that individuals have a diagnosis of Alzheimer’s or irreversible dementia and be deemed by a physician to be in clinical need of a secured unit, criteria that were not supported by the documentation in this resident’s record.